Background: Aortic cusp extension is a technique for aortic valve (AV) repairs in pediatric patients. The choice of the material used in this procedure may influence the time before reoperation is required. We aimed to assess post-operative and long-term outcomes of patients receiving either pericardial or synthetic repairs.Methods: We conducted a single center, retrospective study of pediatric patients undergoing aortic cusp extension valvuloplasty (N=38) with either autologous pericardium (n=30) or CorMatrix (n=8) between April 2009 and July 2016. Short and long-term postoperative outcomes were compared between the two groups. Freedom from reoperation was compared using Kaplan Meier analysis. Degree of aortic stenosis (AS) and aortic regurgitation (AR) were recorded at baseline, post-operatively, and at outpatient follow-up.Results: At five years after repair, freedom from reoperation was significantly lower in the CorMatrix group (12.5%) compared to the pericardium group (62.5%) (P = 0.01). For the entire cohort, there was a statistically significant decrease in the peak trans-valvar gradient between pre- and post-operative assessments with no significant change at outpatient follow-up. In the pericardium group, 28 (93%) had moderate to severe AR at baseline which improved to 11 (37%) post-operatively and increased to 21 (70%) at time of follow-up. In the biomaterial group, 8 (100%) had moderate to severe AR which improved to 3 (38%) post-operatively and increased to 7 (88%) at time of follow-up.Conclusion: In terms of durability, the traditional autologous pericardium may outperform the new CorMatrix for AV repairs using the cusp extension method.
Background: Sedation for lumbar punctures (LPs) in pediatric acute lymphoblastic leukemia (ALL) patients has been the standard for decades to reduce pain and anxiety. Recent studies on the potential long-term neurocognitive effects of cumulative propofol exposure has raised concerns about this practice. The recent pandemic introduced additional burdens to patients, with the requirement of a negative COVID-19 test prior to each sedated procedure. Procedure: These factors prompted a quality improvement intervention at our institution where we aimed to reduce post-Induction sedated lumbar punctures (LPs) by 50%. Our intervention included patient and family education followed by a simulation of the procedure for selected patients. Those converted to unsedated LPs were queried for their preference. Comparative cost, clinical time and LP success rates were collected for sedated and unsedated LPs. Results: Following the intervention, the percentage of LPs performed with sedation dropped from 100% to 48.1%. All LPs were successful using both techniques. Most patients who experienced the unsedated LP technique, and their guardians, strongly preferred this approach. Unsedated LPs significantly reduced clinical time (169 vs 83 minutes) for families, decreased expenditures ($5,736.16 reduction per procedure) and improved institutional opportunity cost due to a decrease in last-minute cancellations. Conclusion: We have shown that it is feasible to significantly reduce the use of sedation for LPs in patients with ALL, which has the potential to improve health and patient experience at a lower cost.
Vaccination is a critical tool in the prevention of COVID-19 infection for individuals and for communities. The mRNA vaccines contain polyethylene glycol (PEG) as a stabilizer. Currently in North America only the BNT162b2 (Pfizer-BioNTech) mRNA vaccine is approved individuals 12 to 17 years of age. Most patients treated with contemporary regimens for acute lymphoblastic leukemia receive Peg-asparaginase and 10-30% will develop allergic reactions. Optimizing access and safety for vaccine administration for these patients critical. This report describes a process developed to support COVID vaccination in a cohort of adolescents and young adults with a history of PEG-asparaginase allergy.
Management of patients with coagulation disorder is a challenge to any surgical specialty. However, fresh diagnosis of a coagulation disorder as result of complications following routine dental treatment is uncommon. We report a case of congenital Factor 13 deficiency diagnosed in a patient presenting with post-dental extraction bleeding.
Runs of homozygosity (ROH) occur when offspring inherit haplotypes that are identical by descent from each parent. Length distributions of ROH are informative about population history; specifically the probability of inbreeding mediated by mating system and/or population demography. Here, we investigate whether variation in killer whale (Orcinus orca) demographic history is reflected in genome-wide heterozygosity and ROH length distributions, using a global dataset of 26 genomes representative of geographic and ecotypic variation in this species, and two F1 admixed individuals with Pacific-Atlantic parentage. We first reconstruct demographic history for each population as changes in effective population size through time using the pairwise sequential Markovian coalescent (PSMC) method. We find a subset of populations declined in effective population size during the Late Pleistocene, while others had more stable demography. Genomes inferred to have undergone ancestral declines in effective population size, were autozygous at hundreds of short ROH (<1Mb), reflecting high background relatedness due to coalescence of haplotypes deep within the pedigree. In contrast, longer and therefore younger ROH (>1.5 Mb) were found in low latitude populations and populations of known conservation concern, including a Scottish population, for which 37.8% of the autosomes comprised of ROH >1.5 Mb in length.
A young girl post-stick injury presented with traumatic cataract and lens neovascularization in OS and iris coloboma, key whole pupil, and cataractous changes in OD. Fundoscopy revealed chorioretinal coloboma OD and retinal detachment on B scan OS. In view of guarded visual prognosis, the patient was advised observation in OU
Human–wildlife conflicts have intensified by many folds and at different levels in the recent years. The same is true in the case of the Hindu Kush Himalaya (HKH), the roof of the world and a region known for its wealth in biodiversity. We present systematic literature review (SLR) using the search, appraisal, synthesis, and analysis (SALSA) framework; and for spatial and network analysis, we employed the VOSviewer software. The review – covering 240 peer- articles within a span of 27 years (from 1982 to 2019) – revealed that in the last decade of that period, there was a 57 per cent increase in publications but with disproportionate geographical and thematic focus. About 82 per cent of the research concentrated on protected areas large carnivores and mega herbivores played a big role in such conflicts. About 53 per cent of the studies were based on questionnaires based and the main driver was reported was the habitat disturbance of the animals due to land-cover change, urbanization, and increase in human population. On the management front, the studies reported the use of traditional protection techniques like guarding and fencing. Our analysis of 681 keywords revealed prominent focus on ‘human-wildlife conflict’, ‘Nepal’, ‘Bhutan’, ‘Snow Leopard’ and ‘Leopard’ indicating the issue are linked with these species and countries. The involvement of 640 authors from 36 countries indicates increasing interest and Nepal and India are playing key role from the region. As for the spatial and network analysis that was conducted, while it showed variations in terms of localities, there were conspicuous limitations in terms of having a transboundary focus. Thus, particular attention ought to be paid to building transboundary partnerships and improving management interventions; there is also a pressing need to understand the patterns of human–wildlife convergence, especially involving meso mammals.
Background: During non-selective His bundle (HB) pacing, it is clinically important to confirm His bundle capture vs. right ventricular septal (RVS) capture. The present study aimed to validate the hypothesis that during HB capture left ventricular lateral wall activation time, approximated by the V6 R-wave peak time (V6RWPT), will not be longer than the corresponding activation time during native conduction. Methods: Consecutive patients with permanent HB pacing were recruited; cases with abnormal His-ventricle interval or left bundle branch block were excluded. Two corresponding intervals were compared: stimulus-V6RWPT and native HBpotential-V6RWPT. Difference between these two intervals (delta V6RWPT), diagnostic of lack of HB capture, was identified using receiver operating characteristic (ROC) curve analysis. Results: A total of 723 ECGs (219 with native rhythm, 172 with selective HB, 215 with non-selective HB, and 117 with RVS capture) were obtained from 219 patients. The native HB-V6RWPT, non-selective-, and selective-HB paced V6RWPT were nearly equal, while RVS V6RWPT was 32.0 (±9.5) ms longer. The ROC curve analysis indicated delta V6RWPT > 12 ms as diagnostic of lack of HB capture (specificity of 99.1% and sensitivity of 100%). A blinded observer correctly diagnosed 96.7% (321/332) of ECGs using this criterion. Conclusions: We validated a novel criterion for HB capture that is based on the physiological left ventricular activation time as an individualized reference. HB capture can be diagnosed when paced V6RWPT does not exceed the value obtained during native conduction by more than 12 ms, while longer paced V6RWPT indicates RVS capture.
A patient with internal carotid artery (ICA) rupture due to multiple irradiations underwent revascularization with high-flow bypass under the condition that endovascular treatment could not be performed. It was possible to safely remove necrotic tissues and reconstruct the skull base using trapping of the ruptured ICA.
Impact of Pre-ablation Weight Loss on the Success of Catheter Ablation for Atrial FibrillationAbdul Hafiz Al Tannir BS, Marwan M. Refaat MDDepartment of Internal Medicine, Division of Cardiology, American University of Beirut Medical Center, Beirut, LebanonRunning Title: Pre-ablation Weight Loss and Success of AF AblationDisclosures: NoneFunding: NoneKeywords: Cardiac Arrhythmias, Cardiovascular Diseases, Heart Diseases, Weight Loss, Catheter Ablation, Atrial FibrillationWords: 621 (excluding references)Correspondence:Marwan M. Refaat, MD, FACC, FAHA, FHRS, FASE, FESC, FACP, FRCPAssociate Professor of MedicineDirector, Cardiovascular Fellowship ProgramDepartment of Internal Medicine, Cardiovascular Medicine/Cardiac ElectrophysiologyDepartment of Biochemistry and Molecular GeneticsAmerican University of Beirut Faculty of Medicine and Medical CenterPO Box 11-0236, Riad El-Solh 1107 2020- Beirut, LebanonFax: +961-1-370814Clinic: +961-1-759616 or +961-1-355500 or +961-1-350000/+961-1-374374 Extension 5800Office: +961-1-350000/+961-1-374374 Extension 5353 or Extension 5366 (Direct)Email: email@example.comIn the United States, the prevalence of obese individuals has risen 3-fold since 1960, with 1 in every 3 persons being obese. The effect of weight changes on the progression on atrial fibrillation is well-established but the effect of pre-ablation weight loss on the recurrence of atrial fibrillation is not well-studied. Atrial fibrillation is the most frequently encountered cardiac arrhythmia ; it currently affects around 2.7 million people in the United States of America and is estimated that 6-12 million people will suffer from this condition by 2050 [2, 3]. Pulmonary vein isolation is the primary target for cardiac ablation; it can be achieved either by radiofrequency (RF) or cryoballoon ablation (CBA) [4, 5]. The FIRE and ICE trial conducted by Kuck et al showed that CBA therapy was associated with significantly fewer recurrence, rehospitalization, and cardioversion rates . Several studies suggest the preferred use of CBA in treating atrial fibrillation in obese patients due to the increased surface area for ablation .Obesity has adverse effects on the structure and hemodynamics of the heart and it is a well-established risk factor for the development of atrial fibrillation . A prospective cohort study performed by Pathak et al showed that progressive weight loss in obese and overweight patients resulted in dose-dependent effects on freedom from atrial fibrillation (FFAF) . Similarly, Middeldrop et al, concluded that obesity is associated with the progression of the disease while weight loss is associated with reversal of the progression . Limited data is available regarding the effect of weight loss on the recurrence of atrial fibrillation post-ablation. Current guidelines recommend lifestyle modifications, including a healthy diet and exercise, for overweight and obese patients before ablation [8, 9].The study of Peigh et al. is a retrospective cohort study from 2012-2017; 607 patients met the inclusion criteria. The aim of the study is to assess the impact of patient-directed weight loss 1 year before CBA on FFAP 15 months after ablation. The authors addressed an important topic that is poorly understood. Obese patients have a significantly lower FFAF rate 40-50% than the overall population 60-80%. The study selectively included patients undergoing CBA therapy. The follow-up time was 1-year post-ablation. The study concluded that, with the exception of non-obese patients with persistent atrial fibrillation, weight loss is associated with a significantly increased FFAF while weight gain led to a decrease in FFAF. A similar study assessed the impacted of physician-mediated risk control in patients undergoing RF ablation for atrial fibrillation . A total of 149 patients were included in the prospective cohort study. The study showed a positive association between physician-directed weight loss (≥ 10%) and FFAF in symptomatic obese patients. The study performed by Peigh et al, included though a larger subject group (607) than LEGACY (141); however, the LEGACY is a prospective cohort study that is more suitable to monitor the fluctuation in patients’ variables before ablation.This study was well conducted but has the limitations of retrospective studies; a prospective cohort study would better monitor the variations in patients’ variables pre-ablation. In addition, as the authors stated, asymptomatic atrial fibrillation episodes may go unnoticed.Patients with atrial fibrillation, particularly those who are obese, should be advised to lose weight prior to catheter ablation. Lifestyle modifications should not be limited to patients undergoing ablation; the effect of weight loss on disease progression is well-established. Due to the overgrowing prevalence of atrial fibrillation and obesity worldwide, more studies are encouraged to better understand the ideal lifestyle management in patients. Larger prospective cohort studies should be conducted in order to validate the results. There is also an ongoing randomized clinical trial BAROS (Bariatric Atrial Return of Sinus Trial) [NCT 04050969] which will provide more data on this topic.
Ventricular tachycardia (VT) normally occurs from an abnormal structural substrate. We report a case in which VT was caused by a large tumor in the interventricular septum. Surgical intervention was not an option due to the location of the tumor and its proximity to the coronary arteries. The patient underwent ablation and upgrade to CRT before ultimately receiving a heart transplant.
It is well known that the left internal mammary artery (LIMA) should be the first conduit of choice. Similarly, especially in patients younger than 70 years, other conduits should be search among arterial grafts such as right internal mammary artery (RIMA) or radial artery (RA). If the RA can be harvested in the meanwhile of LIMA harvesting without time consuming, it is well established that former one has to be grafted only on presence of a good run-off. One of the main criticisms moved to the use of RIMA are linked to technical difficulties in its harvesting it. Edgar Aranda-Michel and coworkers tried to answer to the age-old question is “RIMA has to be used in situ or free-graft?” In a retrospective study on 667 patients (442 had free RIMA and 245 had free RIMA) that were also matched through propensity analysis (202 patients per group), they did not find any differences between the two groups in the major outcomes, including heart failure specific readmissions. This finding is consistent with the literature, hence the take-home message is whatever happens, two mammary is better than one.
Telemedicine, telehealth and artificial intelligence in healthcare are becoming commonly utilized in various medical specialties. The article authored by Dr. Aminah Sallam and colleagues in the Journal provides data in support of the cardiac surgical patients, and the caring cardiac surgeons willingness to adopt telemedicine as a method of connectivity between patient and surgeon.
We describe two cases of microlaryngeal surgery under general anesthesia in severe obese elite vocal performers. Microlaryngeal surgery under general anesthesia is feasible in patients with severe obesity, provided that the anesthesiologist and nurse work together to perform preoperative simulations and take into consideration the position and anesthesia.
Background: There is limited data to inform minimum case requirements for training in robotically-assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on non-clinical endpoints and expert opinion. Objectives: To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes. Methods: We included isolated RA-CABG in The Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics. Results: There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon’s 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model case sequences of >10 was an independent predictor of decreased approach conversion (OR 0.27, 95% CI 0.09 to 0.84) and increased rate procedural success (OR 1.96, 95% CI 1.00 to 3.84).